Provider Demographics
NPI:1376956318
Name:MANURUNG, ALEXANDRA DEPTULA (MS, LAT, ATC, PTA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:DEPTULA
Last Name:MANURUNG
Suffix:
Gender:F
Credentials:MS, LAT, ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1006
Mailing Address - Country:US
Mailing Address - Phone:410-340-1046
Mailing Address - Fax:
Practice Address - Street 1:715 CARTER RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-1006
Practice Address - Country:US
Practice Address - Phone:410-340-1046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-07
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA002082255A2300X
MDA4337225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer